More is not always better: 2 weeks of intensive cognitive processing therapy-based treatment are noninferior to 3 weeks.

Abstract

Objective: Although there is mounting evidence that massed treatment for PTSD is both feasible and effective, many questions remain about the optimal length of intensive treatment programs (ITPs), as well as the role of adjunctive services, such as psychoeducation, mindfulness, and yoga. Our setting recently transitioned from a three-week ITP to a two-week program. Adjunctive services were reduced, but the amount of individual CPT between programs remained similar. The present study examined the effectiveness of a two-week ITP based on twice daily individual CPT sessions and evaluated the program's noninferiority to an established three-week ITP using a Bayesian analytical approach. Method: Bayesian linear mixed regression models were used to explore PTSD and depression changes over time, as well as predictors of change. Noninferiority of the two-week ITP to a three-week ITP was also established using a Bayes factor approach. Results: Results indicate that program participants change meaningfully in both PTSD and depression severity over the course of treatment, and that changes in posttraumatic cognitions predict subsequent changes in these outcomes. Further, the two-week ITP can be considered noninferior to the three-week ITP in both clinical outcomes and overall satisfaction. Conclusions: In the context of intensive PTSD treatment, the content of the ITP appears to matter more than its overall length. Shorter programs have the potential to increase access and treatment capacity. Our findings demonstrate the importance of continuous and rigorous program evaluation. Limitations as well as future directions for research, such as identifying the most effective treatment components, are discussed. Clinical Impact StatementThe present study compared 2 intensive treatment programs for veterans with posttraumatic stress disorder (PTSD). The 2-and 3-week-long programs were based on daily Cognitive Processing Therapy (CPT) as well as adjunctive services. The two-week program had fewer overall service hours but offered a comparable amount of CPT. Both programs produced large and equivalent PTSD and depression severity reductions. The findings suggest that the more/longer treatment is not necessarily better and that content of the intensive PTSD treatment programs appears to matter more than its overall length. Shorter PTSD treatment programs have the potential to increase access and capacity.

Building strong therapeutic relationships quickly: The effect of the perceived working alliance on veterans’ intensive PTSD treatment outcomes.

“…For example, it is possible that the adjunctive services may have facilitated veteran-perceived working alliance. However, given the previously described substantial difference between the two ITPs examined in this study with regard to their content and duration and amount of adjunctive services (Held et al, 2022), together with the similar results regarding the perceived working alliance across both programs, we would not suspect that any of the specific adjunctive components would have substantially influenced working alliance ratings. Instead, we would hypothesize that overall positive experiences with the program may have influenced veterans’ ratings of their working alliance with their individual CPT therapist.…”

“…Curiously, findings regarding the perceived strength of the bond or the agreement on therapeutic goals were inconsistent between the 2- and 3-week ITPs. We are uncertain what may have led to these inconsistent findings between two relatively similar programs that have been shown to produce similar outcomes (Held et al, 2022). These findings highlight the previously noted complexity between working alliance and clinical outcomes (Miles-McLean et al, 2019).…”

“…Prior research has demonstrated that treatment outcomes for both cohort types in the 3-week ITP are equivalent (Lofgreen et al, 2020). For a more detailed description of the 3-week ITP, including acceptance and client flow, as well as pre- to post-treatment outcomes (see, Held et al, 2022; Held, Klassen, et al, 2020; Zalta et al, 2018, respectively).…”

“…Veterans in the 2-week ITPs were treated in separate combat trauma or military sexual trauma cohorts, which were nearly identical in their programming. The 2-week ITP treatment outcomes have been shown to be noninferior to those of the 3-week ITP (Held et al, 2022).…”

Evaluating changes in negative posttrauma cognition as a mechanism of PTSD severity changes in two separate intensive treatment programs for veterans

“…In the 2-week program, veterans received a total of 67 hours of clinical programming. Both the 3-and 2-week intensive PTSD treatment programs have been described in additional detail elsewhere and been shown to provide equivalent results despite the differences in treatment length and programming [32].…”